Impact of a Transitional Care Program on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward

Not Applicable

Completed

Interventions: Other: Transitional care program.
Other: standard care program

Brief Summary: In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% \[12.0-16.7\]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a program of transitional care from hospital to home for people of 75 years old or more admitted to acute care.

Detailed Description: The study is a stepped wedge randomized cluster study. Intervention: The transition care program, involving a dedicated advanced practice nurse, will include: 1) during the patient's stay in hospital: an individualized needs-based comprehensive discharge plan and a transitional care record ; the notification of the primary care physician about inpatient care and hospital discharge; 2) the day of the discharge: specific explanations about the organization of home care provided by the transition care nurse to the patient; 3) during 4 weeks after discharge: monitoring patients and caregivers regularly through home visits and/or telephone contact,

Recruitment & Eligibility

Inclusion Criteria

Patient hospitalized for 48 hours or more in one of the acute geriatric service participating to the study.
Aged 75 or older.
Leaving at home and with home as the planned discharge after the admission.
At risk of hospital readmission emergency visit rates after discharge (if he has two or more of the following criteria (taken from the Triage Risk Screening Tool and from the 2013 French recommendation)).

Exclusion Criteria

Patient leaving in a retirement home.
Patient hospitalized at home.
Patient leaving at home but at 30 km (18 miles) or more from the service of his index admission

Arm && Interventions

Group	Intervention	Description
Transitional care program.	Transitional care program.	The transitional care program from hospital to home will be implemented at three steps: during the patient's stay in hospital, the day of the discharge and during 4 weeks after discharge.
standard care program	standard care program	No intervention liable to affect the care provided to the patients, the organization of care or the practices of health care professionals will be implemented during the control period (time steps without intervention).

Primary Outcome Measures

Name	Time	Method
30-Day unscheduled hospital readmission or emergency visit rate after the index hospital discharge.	Within 30 days after hospital discharge.	Unscheduled hospital readmissions are hospitalizations that are not planned at the moment of the discharge (for example: hospitalization after an emergency visit or upon request of the primary care physician).

Secondary Outcome Measures

Name	Time	Method
Adverse events (i.e. falls)	Within 30 days after the index hospital discharge.
Length of stay in the short stay geriatric ward (index hospitalization)	Patients will be followed for the duration of hospital stay, an expected average between 2 days and 30 days
Free-hospitalization survival	Within 30 and 90 days after the index hospital discharge.
Mortality rate	Within 30 and 90 days after the index hospital discharge.
Unscheduled hospital readmissions or emergency room visits	Within 30 and 90 days after the index hospital discharge.
Patients' satisfaction care transition programme	Within 30 days after the index hospital discharge.	Measured with the Care Transition Measure® questionnaire.
Number of contacts between the transition nurse and the primary care providers or the hospital providers after discharge	Within 30 days after the index hospital discharge.
Costs of unscheduled hospital readmission or emergency visit	30 days after discharge	Hospital and community care costs after discharge
Quality of life.	Within 30 days after the index hospital discharge.	Measured with the French version of the EUROQOL-5D.
Delay between the index hospital discharge and the implementation of home care.	Within 30 days after the index hospital discharge.

Locations (9): Hôpital Édouard Herriot
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Lyon, France
CH Gériatrique des Monts d'Or
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Albigny sur Saône, France
CH Bourg-en-Bresse
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Bourg en Bresse, France
Centre Hospitalier Alpes Léman
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Contamine sur Arve, France
CHG Annecy
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Pringy, France
Centre Hospitalier Lyon Sud
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Pierre Benite, France
Clinique des portes du sud
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Venissieux, France
CH Villefranche
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Villefranche, France
CH Saint-Chamond
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Saint Chamond, France